Complaints and appeals

Complaints (grievances)

Your network providers and Providence Health Assurance want to give you the best possible care. But if you have a complaint about any part of your care, you can call or write to Providence Health Assurance.

Timeframe

• Our staff will work to address each of your concerns and resolve them within five (5) business days.
• If your complaint needs more follow up, you will receive a call or letter within five (5) business days.
• We will provide a final answer to you within 30 calendar days.

If you need assistance, you can call Providence Health Assurance Customer Service at 503-574-8200 or 800-898-8174 (TTY/TDD 711).

Other options:

• You may also contact your provider directly to talk about your concerns
  
  OR
• File a complaint with:
  OHP Client Services by calling 800-273-0557
  The Oregon Health Authority Ombudsman at 503-947-2346 or toll-free at 877-642-0450. 
  
  

Below are links to the forms and information you will need:

• OHP Complaint Form - English
• OHP Complaint Form - Spanish
• OHP Complaint Form - Russian
• OHP Complaint Form - Vietnamese
• OHP Complaint Form - Arabic
• OHP Complaint Form - Somali

Appeals

If you receive a Notice of Action letter, you can appeal our decision in writing. If you need assistance with this process please contact Customer Service at the number below.

You must file the appeal within 60 days from the date on the letter.

We will resolve your Appeals as expeditiously as your health condition requires and no later than sixteen (16) days from the day we receive the Appeal. We can extend this timeframe by 14 days but we will let you know. We will send you a letter within 30 days.

You can keep on getting a service that already started before our decision to deny, stop or reduce it. You must ask us to continue the service within 10 days of getting the Notice of Action/Benefit Denial.

If we uphold our decision, you may be responsible for the cost of the services you received after the effective date on the Notice of Action/Benefit Denial.

Please note: If your provider is contracted with PHA, they can also file an appeal with your written permission. Your provider can also support your appeal by sending us your medical records when we ask for them, or by including them with the appeal.

If your provider files an appeal on your behalf, the provider may request a contested case hearing if they do not agree with the appeal decision.

Contact us if your problem is solved at any step in this process.

Expedited appeals for urgent medical problems

If you believe your medical problem cannot wait for a regular appeal, ask PHA for an expedited (fast) appeal. You should include a statement from your provider why it is urgent. Or you can ask your provider to call us. If we agree that it is urgent we will call you with a decision within 72 hours.

Administrative hearings

If you do not agree with our decision on your appeal, you may request a hearing from the Oregon Health Authority. Your Notice of Appeal Resolution letter will have a Hearing Request form that you can mail in, to ask the state for a hearing. You can also ask Health Share/Providence Customer Service to send you a Hearing Request form, or call OHP Client Services at 800-273-0557 (TTY/TDD: 711) to ask for a form.

If you have questions about this process contact Customer Service or OHP Client Services for more information. More information is also available in your Health Share Member handbook.